1
Treating Emergency Room Opioid
Withdrawal with Buprenorphine
Monday, February 11th (3:45pm – 4:30pm) Room W314B
Christine Bucago, Advanced Practice Clinical Leader (Nursing), CAMH
Jane Paterson, Director, Interprofessional Practice, CAMH
2
Christine Bucago RN, MN, CPMHN(C); Advanced Practice Clinical
Leader (Nursing), Acute Care Program
AND
Jane Paterson, MSW, RSW; Director, Interprofessional Practice
Have no real or apparent conflicts of interest to report.
Conflict of Interest
3
Agenda
• Origins
• Transformation
• Data-Driven Organization
• Achievements
Introduction to
CAMH
• Local Problem
• Design and Implementation
• How Health IT was used
• Value Derived
Buprenorphine
Treatment
4
• Review the clinical benefits of prescribing buprenorphine rather
than other medications to ease opioid withdrawal symptoms
• Outline how to design a clinical workflow, which standardizes how
care is delivered to patients in opioid withdrawal visiting an
emergency department.
• Describe how to construct the key elements to embed clinical
decision support in the form of a buprenorphine order set to
ensure that patients in opioid withdrawal receive the most effective
care at the right time
Learning Objectives
5
CAMH Overview
6
Toronto
Location
CAMH is located in downtown Toronto, Canada
7
CAMH Transforming Lives
Largest mental health and addictions
hospital in Canada
University of Toronto - affiliated teaching
hospital
World leader in brain science
3 main sites with 30+ locations
90 distinct clinical services: eg.
emergency department, inpatient,
outpatient, day treatment, forensic,
partial hospitalization programs and
other specialty services
8
CAMH Clinical Programs
Acute Care
Complex Care
and Recovery
(CCR)
Clinical Services
• ED (Emergency
Department) and
Inpatient Services
• Outreach &
Telemedicine
• Ambulatory Services
• CCR Inpatient
Services
• CCR Outpatient
Services
• CCR Specialized
Services and
Research
• Clinical
Operations
• Clinical
Laboratory
and
Diagnostic
Services
• Pharmaceutica
l Services
• Medical
Services
• Hospitalist
Services
• Infection
Prevention
and Control
• Dental Clinic
• Podiatry
Clinics
• Dietetic
Services
• Nursing
Resource Unit
Child, Youth &
Emerging Adult
• Child, Youth &
Emerging Adult
Services
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CAMH Origins - 1848
Provincial Lunatic Asylum
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Merger of Founding Organizations – 1999
Donwood Institute
Queen Street Mental Health Centre
Clarke Institute of Psychiatry
Addiction Research Foundation
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CAMH Key Statistics
2017-2018 Report
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Roadmap to Data-Driven Care
IT Infrastructure
Optimization
Centralized Intake Process
Enterprise
Reporting
Integrated Care Pathways
Krembil Centre for
Neuroinformatics
Clinical Information
System
Transformation
Performance
Improvement / Business
intelligence
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Why the Davies Award?
International recognition that CAMH leverages its clinical information system to support
excellence in care delivery and identify ongoing improvement opportunities, in support of our
overarching strategic vision.
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Treating Emergency Room
Opioid Withdrawal with
Buprenorphine
15
Agenda
Problem
Identification /
Importance
Baseline
Workflow
Baseline Data
Design and
Implementation
Local Problem
How Health IT was Used
Value Derived
Objectives
Solution Selection
Interventions
End-User
Involvement
Revised Workflow
Solution Details
Effect of Interventions
on Data
Post-Implementation
Adherence Data
Post-Implementation
Outcome Data
Return on Investment
Problem Identification /
Importance
Baseline Workflow
Baseline Data
Objectives
Solution Selection
Interventions
End-User Involvement
Revised Workflow
Solution Details
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Opioid Crisis in Canada
Number (January to September) and estimated annual rate (per 100,000 population) of apparent opioid-related deaths by province or territory, 2017
• Canada is facing a national opioid crisis
• Over recent years, there has been an
alarming increase in the number
overdoses and deaths caused by opioids
Source: Health Canada. Apparent opioid-related deaths. Retrieved from: https://www.canada.ca/en/health-
canada/services/substance-abuse/prescription-drug-abuse/opioids/apparent-opioid-related-deaths.html
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
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Problem Identification
• CAMH provided Clonidine (comfort measure) as a treatment for individuals presenting to
the Emergency Department (ED) with opioid withdrawal
• There is an additional treatment for opioid withdrawal (buprenorphine)
Problem Identification
• CAMH identified new Health Quality Ontario opioid use disorder standards including:
• Administration of opioid agonist therapy within 3 days of presentation
• Opioid agonist therapy should be administered within 2 hours
• Distribution of take-home naloxone kits
• As the leading national academic mental health and addictions hospital, CAMH must lead
the way with best-practice treatments
• Buprenorphine has a “ceiling effect” and slow action onset, meaning minimal overdose risk
• Patients on a maintenance dose may have a blunted analgesic and euphoric response if
they take other opioids concurrently
Why is this Important?
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
18
Initial Baseline Workflow
Patient
presents to
ED with
opioid
withdrawal
Continue
treatment
Clonidine
order set
selected
Refer to CAMH
Medical
Withdrawal
Service, Addiction
Medicine Service,
or community
non-medical detox
Decision
to
prescribe
Clonidine
Symptoms
relieved?
Discharge
from ED
Yes
No
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
19
Baseline Data
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
2015 Q4 – 2016 Q3
Clonidine Initiations 20.8%
Buprenorphine Initiations 8.5%
0%
10%
20%
30%
40%
50%
2015 Q4 2016 Q1 2016 Q2 2016 Q3
Percentage of Initiations
Calendar Quarter
Percentage of Initiations for Opioid Withdrawal Patients
Suboxone Initiations Clonidine Initiations
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Objectives
Standardize pathway and treatment protocol
for buprenorphine
Create barrier-free and timely access to
continuing care
Streamline ordering process to save clinician
time and prevent errors
Adhere to new Health Quality Ontario
standards for opioid withdrawal and opioid use
disorder
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
21
Solution Selection
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Standardized
practice
Standardized
documentation
Communicatio
n tools
Tracking and
feedback
Clinician
familiarity
Dynamic
reporting
Existing
change
management
Existing
governance
Options reviewed and selected by CAMH Addiction Medicine Service and ED
management with staff consultation:
-Experience with other order sets showed positive practice change
CAMH identified a method to ensure increased use of buprenorphine within the ED.
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Interventions
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
• Partnership between CAMH
Addiction Medicine Service
and Emergency Department to
build capacity for addictions
treatments, including
buprenorphine (Nov 2016 –
Mar 2017)
• Education sessions including
benefits, initiation, and
administration of
buprenorphine for all ED staff
(May – June 2017)
• Creation of an interdisciplinary
buprenorphine pathway and
buprenorphine order set
(August 2017 go-live)
Addiction Medicine Service
Partnership
Education Sessions
Order Set
And Pathway
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Strategic Governance
** Advisory / Working Groups established as
required
High-level Decisions
Mid-Level
Decisions
Medical Advisory
Committee
Physician in Chief
Health Information
Interdisciplinary
Committee
Dir. Interprof. Practice
Dir. Medical Informatics
Executive Leadership
Team
CEO
Physician /
Hospitalist User
Groups
Dir. Medical Informatics
Lead Hospitalist
Pharmacy &
Therapeutics
Dir. Pharmacy
Order Sets
Sub-Committee
Dir. Medical
Informatics
Pharmacist
Practice Adoption &
Optimization Council
Manager, Clinical
Education
Advanced Practice
Clinical Lead
Clinical Applications
Change Advisory
Board
Sr. Manager, Clinical
Applications
Data and Reporting
Governance Committee
(ELT Sub-Committee)
Exec. Dir. Performance
Improvement
Med. Dir. Performance
Improvement
Collaborative Practice
Advisory Committee
Chief of Nursing
APPROVED
Clinical Care Committee
Dir. Interprofessional
Practice
Chief Medical Officer
Integrated Health Record Council
Dir. Clinical Information Systems
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
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End-User Involvement
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
• Co-chairs: Appointed Physician and Dir. Pharmacy
• Owners and approvers of Order Set
• Includes a minimum of 6 physicians, 4 pharmacists
• Chairs: Dir. Medical Informatics, Pharmacist
• Assembled subject matter clinical experts for review of
order sets
Pharmacy & Therapeutics
Order Sets Sub-Committee
• Chair: Physician in Chief
• High-level review and recommendations regarding the
practice of medicine at CAMH
Medical Advisory Committee
• Chairs: Dir. Interprofessional Practice, Dir. Medical
Informatics
• Includes clinicians and other stakeholders
• Initial approval of need
Integrated Health Record
Committee
Revised Workflow
Patient presents
to ED with opioid
withdrawal
Reassess in 2
hours *
Clinical Opiate
Withdrawal
Scale
completed *
Administer
buprenorphine*
Does patient
agree to
buprenorphine
treatment?
Symptoms
relieved?
Re-assess in
2 hours
Yes
Health IT used within intervention*
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Result
>12? *
Proceed with
Clonidine or
alternative
treatment
No
Yes
Total daily
dose
established
Administer
additional
dose
Refer to CAMH
Addiction Medicine
Service, prescribe total
daily dose, provide
Naloxone kit and
information *
Yes
No No
Discharge
from ED
Buprenorphine
induction order
set selected*
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Suboxone Order Set
Rapid Access
Referral
Free Naloxone kit
flyer
Administration
guidelines
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Dosage options
Clinical Opiate
Withdrawal Scale
• Standardized Lab orders
• Vital signs
• Clinical Opiate Withdrawal Scale
• Rapid Access Referral
• Distribution of Naloxone kits
• Patient education materials
Buprenorphine Order Set
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Clinical Opiate Withdrawal Scale (COWS)
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Automated scoring
Key
• Used in ED for patients
presenting with opiate
withdrawal symptoms
• Recommended for use during
buprenorphine induction
• <2 minutes for completion
COWS
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Rapid Access Referral
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Rapid access auto-
populates
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Effect of Interventions on Data
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
AMS Partnership Education Sessions
Order Set
and Pathway
• Partnership between CAMH
Addiction Medicine Service
and Emergency Department
to build capacity for
addictions treatments,
including buprenorphine
(Nov 2016 – Mar 2017)
• Education sessions including
benefits, initiation, and
administration of
buprenorphine for all ED staff
(May – June 2017)
• Creation of an
interdisciplinary
buprenorphine pathway and
buprenorphine order set
(August 2017 go-live)
Intervention
Outcomes
• Created clinical awareness
• Generated familiarity and
comfort with prescribing
opioid agonist therapy
• Created practice guidelines to
educate staff about
buprenorphine and its use
within opioid withdrawal and
maintenance therapy
• Created clinical awareness
and enforced regulations to
standardize practice for
buprenorphine patients
• Provided rapid access referral
option to support evidence-
based practice
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2
Percentage of Initiations
Calendar Quarter
Percentage of Initiations for Opioid Withdrawal Patients
Suboxone Initiations Clonidine Initiations
Post-Implementation Adherence Data
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
2015 Q4 – 2016 Q3 2017 Q3 – 2018 Q2
Clonidine Initiations 20.8% 8.5%
Buprenorphine Initiations
8.5% 28.4%
AMS Partnership Education Order Set
Pre-implementation
Post-implementation
5.1%
5.0%
3.1%
7.9%
5.5%
12.9%
3.0%
6.8%
3.0%
0.0%
4.8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2
Repeat Visits
Calendar Quarter
Repeat ED Visits for Opioid Withdrawal Patients
Repeat ED Visits Within 7 Days
Post-Implementation Outcome Data
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
AMS Partnership
Education
Order
Set
2015 Q4 – 2016 Q3 2017 Q3 – 2018 Q2
Repeat ED Visits within 7 days 5.31% 3.96%
Pre-implementation
Post-implementation
32
Post-Implementation Outcome Data
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
9.3
4.8
0
1
2
3
4
5
6
7
8
9
10
Average Wait Time (Days)
Average wait time between ED and CAMH
AMS rapid access service for Opioid
Withdrawal patients
2015 Q4 – 2016 Q3 2017 Q3 – 2018 Q2
33
Return on Investment
3
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Twenty-four fewer patients with opioid withdrawal diagnoses were admitted to
inpatient after improvements in care due to buprenorphine initiations.
(Cost of ED visit * # ED visits) + (# admitted to IP * LOS * IP day cost)
0
100000
200000
300000
400000
500000
600000
700000
Pre Order Set & Rapid Access Referral
(August 1, 2016 - July 31, 2017)
Post Order Set & Rapid Access Referral
(August 1, 2017 - July 31, 2018)
Cost of Treating Patients
Presenting in ED with an Opioid
Diagnosis who were Admitted to
Inpatient
$628,028
$490,566
Savings =
$137,462
34
Return on Investment
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
Able to treat
opioid
withdrawal on-
site in a safe
and effective
manner
Adhere to
Health Quality
Ontario
guidelines for
opioid agonist
therapy
Reduce repeat
ED visit rates
for opioid
withdrawal
patients
presenting to
ED
35
Lessons Learned
Streamlining the ordering process has been
beneficial to clinicians while emergency volumes
increase
Ongoing efforts are required to ensure residents and
clinicians are confident initiating treatments
Buprenorphine is the most supported treatment
through research, but other medications are
appropriate for some patients
Design and
Implementation
Local Problem
How Health IT
was Used
Value Derived
